Salt Reduction Initiatives around the World - A Systematic Review of Progress towards the Global Target

Making hospital shops healthier: evaluating the implementation of a mandatory standard for limiting food products and promotions in hospital retail outlets

BACKGROUND

The range of products stocked and their promotions in food retail outlets in healthcare settings can affect food choices by staff, patients and visitors. The innovative Scottish Healthcare Retail Standard (HRS) is a national mandatory scheme requiring all hospital food retail outlets to change the balance of food products stocked and their promotion to comply with nutritional criteria and promotional restrictions. The aim is to facilitate healthier food choices in healthcare settings. This study examined the implementation of HRS and the impact on foods stocked and promoted.

METHODS

The study aimed to examine implementation process and changes to the retail environment in relation to food promotions and choice. A sample of hospital retail outlets (n = 17) including shops and trolley services were surveyed using a mixed methods design comprising: (a) structured observational audits of stock, layout and promotions (with a specific focus on chocolate and fruit product lines), and (b) face-to-face, semi-structured interviews with the shop manager or nominated members of staff (n = 32). Data were collected at Wave 1 (2016), at the beginning and during the early stages of HRS implementation; and Wave 2, 12 months later, after the HRS implementation deadline.

RESULTS

All outlets, both commercial and not-for-profit, in the sample successfully implemented HRS. Implementation was reported to be more challenging by independent shop managers compared to chain store staff. Retail managers identified areas where more implementation guidance and support could have been provided. The number of chocolate product lines and promotions reduced substantially between Waves 1 and 2, but with no substantial increase in fruit product lines and promotions. Despite initial negative expectations of HRS's impact, managers identified some opportunities in the scheme and positive changes in the supply chain.

CONCLUSIONS

Positive changes in food retail outlets occurred after hospital shops were required to implement HRS. By creating a consistent approach across hospital shops in Scotland, HRS changed the food retail environment for hospital staff, visitors and patients. HRS provides a regulatory template and implementation learning points for influencing retail environments in other jurisdictions and settings.

Validation of preferred salt concentration in soup based on a randomized blinded experiment in multiple regions in Japan-influence of umami (L-glutamate) on saltiness and palatability of low-salt solutions

Sodium reduction is an important public health goal. Individual and population approaches are necessary for reducing the sodium content of processed foods and meals. The aim of the present study is to affirm the effect of monosodium l-glutamate (MSG), an umami substance, on the saltiness or palatability of low-salt solutions and to explore the preferred salt concentration in soup. Five hundred and eighty-four healthy participants from nineteen regions in Japan tasted 0.3, 0.6, and 0.9% NaCl solutions with or without 0.3% MSG. Evaluations of saltiness and palatability for each solution were conducted using a visual analog scale in a double-blinded randomized manner. Saltiness gradually increased depending on the concentration of NaCl. The saltiness of the 0.3% NaCl solution with MSG was rated significantly higher than that without MSG. The palatability ratings were higher for the solutions with MSG than for those without MSG for all NaCl concentrations. In particular, the palatability rating of the 0.3% NaCl solution with MSG was twice as high as that without MSG and was significantly higher than that of the other five test solutions. Furthermore, these results were observed to be approximately the same, irrespective of sex, age, region, etc. Salt reduction is believed to result in a loss of palatability. However, our results suggest that umami can compensate for the loss of palatability caused by salt reduction and that the addition of an appropriate amount of an umami substance can facilitate salt reduction from 0.9 to 0.3% without sacrificing palatability.

Reduced-sodium cheeses: Implications of reducing sodium chloride on cheese quality and safety

Sodium chloride (NaCl) universally well-known as table salt is an ancient food additive, which is broadly used to increase the storage stability and the palatability of foods. Though, in recent decades, use of table salt in foods is a major concern among the health agencies of the world owing to ill effects of sodium (Na) that are mostly linked to hypertension and cardiovascular diseases. As a result, food scientists are working to decrease the sodium content in food either by decreasing the rate of NaCl addition or by partial or full replacement of NaCl with other suitable salts like potassium chloride (KCl), calcium chloride (CaCl₂ ), or magnesium chloride (MgCl₂ ). However, in cheese, salt reduction is difficult to accomplish owing to its multifaceted role in cheese making. Considering the significant contribution in dietary salt intake (DSI) from cheese, researchers across the globe are exploring various technical interventions to develop reduced-sodium cheeses (RSCs) without jeopardizing the quality and safety of cheeses. Thus, the purpose of this study is to provide an insight of NaCl reduction on sensory, physicochemical, and technofunctional attributes of RSCs with an aim to explore various strategies for salt reduction without affecting the cheese quality and safety. The relationship between salt reduction and survival of pathogenic and spoilage-causing microorganisms and growth of RSCs microflora is also discussed. Based on the understanding of conceptual and applied information on the complex changes that occur in the development of RSCs, the quality and safety of RSCs can be accomplished effectively in order to reduce the DSI from cheese.

Parents' Perceptions about Salt Consumption in Urban Areas of Peru: Formative Research for a Social Marketing Strategy

Background: Salt intakes in Latin America currently double the World Health Organization’s recommendation of 5 g/day. Various strategies to reduce the population’s salt consumption, such as raising awareness using social marketing, have been recommended. This study identified parents’ perceptions of salt consumption to inform a social marketing strategy focused on urban areas in Peru. Methods: Using a sequential exploratory methods design, parents of pre-school children, of high and low socioeconomic status, provided qualitative data in the form of interviews and focus groups. Following this, quantitative data was obtained via questionnaires, which were sent to all parents. The information was analyzed jointly. Results: 296 people (mean age 35.4, 82% women) participated, 64 in the qualitative and 232 in the quantitative phase of the study. Qualitative data from the first phase revealed that the majority of mothers were in charge of cooking, and female participants expressed that cooking was “their duty” as housewives. The qualitative phase also revealed that despite the majority of the participants considered their salt intake as adequate, half of them mentioned that they have tried to reduce salt consumption, and the change in the flavor of the food was stated as the most difficult challenge to continue with such practice. Quantitative data showed that 67% of participants would be willing to reduce their salt intake, and 79.7% recognized that high salt intake causes hypertension. In total, 84% of participants reaffirmed that mothers were in charge of cooking. There were no salient differences in terms of responses provided by participants from high versus low socioeconomic groups. Conclusions: The results point towards the identification of women as a potential target-audience of a social marketing strategy to promote reductions in salt intake in their families and, therefore, a gender-responsive social marketing intervention is recommended.

Cardiovascular Diseases Deaths Attributable to High Sodium Intake in Shandong Province, China

Background

High sodium intake elevates blood pressure and thereby raises cardiovascular diseases (CVDs). Sodium intake is high in northern China, including Shandong province where the SMASH (Shandong‐Ministry of Health Action on Sodium and Hypertension) is currently underway.

Methods and Results

Blood pressure values and sodium intake measurements using 24‐hour urinary excretion were collected from the 2011 SMASH baseline survey, which was conducted in 20 counties/districts using a multistage stratified cluster random sampling method. We derived cause‐specific mortality from the Shandong Death Registration System (SDRS) during the same year and used population‐attributable fraction to estimate annual CVDs deaths attributable to high sodium intake (mediated through elevated systolic blood pressure) and CVD deaths averted by achieving different sodium‐reduction targets. Overall, 16 100 (95% uncertainty intervals, 11 000–22 600) CVD deaths among adults aged 25 to 69 years, including 5600 (4000–6500) for ischemic heart disease and 9000 (6700–11 600) for stroke, were attributable to higher sodium intake (2000 mg/day or 5.0 g/day of salt as a reference) in Shandong in 2011, accounting for 19.9% (13.7–25.0%) of total CVD deaths. The benefit of CVD deaths from sodium reduction is considerable with 8800 (6400–13 600), 6700 (4900–11 600), and 8500 (6000–10 800) averted, respectively, if sodium intake was reduced from the 2011 baseline to 3500 mg/day, 4000 mg/day, or reduced by 30%.

Conclusions

Nearly 20% of CVD deaths among adults aged 25 to 69 years could be attributable to the systolic blood pressure–raising effect of high sodium intake in Shandong in 2011. Potential benefits from population reduction of sodium intake are considerable.

High-Salt Diet Causes Sleep Fragmentation in Young Drosophila Through Circadian Rhythm and Dopaminergic Systems

Salt (sodium chloride) is an essential dietary requirement, but excessive consumption has long-term adverse consequences. A high-salt diet (HSD) increases the risk of chronic diseases such as cardiovascular conditions and diabetes and is also associated with poor sleep quality. Little is known, however, about the neural circuit mechanisms that mediate HSD-induced sleep changes. In this study, we sought to identify the effects of HSD on the sleep and related neural circuit mechanisms of Drosophila. Strikingly, we found that HSD causes young Drosophila to exhibit a fragmented sleep phenotype similar to that of normal aging individuals. Importantly, we further showed that HSD slightly impairs circadian rhythms and that the HSD-induced sleep changes are dependent on the circadian rhythm system. In addition, we demonstrated that HSD-induced sleep changes are dopaminergic-system dependent. Together, these results provide insight into how elevated salt in the diet can affect sleep quality.

A comparison of the healthiness of packaged foods and beverages from 12 countries using the Health Star Rating nutrient profiling system, 2013-2018

We compared the healthiness of packaged foods and beverages between selected countries using the Health Star Rating (HSR) nutrient profiling system. Packaged food and beverage data collected 2013-2018 were obtained for Australia, Canada, Chile, China, India, Hong Kong, Mexico, New Zealand, Slovenia, South Africa, the UK, and USA. Each product was assigned to a food or beverage category and mean HSR was calculated overall by category and by country. Median energy density (kJ/100 g), saturated fat (g/100 g), total sugars (g/100 g) and sodium (mg/100 g) contents were calculated. Countries were ranked by mean HSR and median nutrient levels. Mean HSR for all products (n = 394,815) was 2.73 (SD 1.38) out of 5.0 (healthiest profile). The UK, USA, Australia and Canada ranked highest for overall nutrient profile (HSR 2.74-2.83) and India, Hong Kong, China and Chile ranked lowest (HSR 2.27-2.44). Countries with higher overall HSR generally ranked better with respect to nutrient levels. India ranked consistently in the least healthy third for all measures. There is considerable variability in the healthiness of packaged foods and beverages in different countries. The finding that packaged foods and beverages are less healthy in middle-income countries such as China and India suggests that nutrient profiling is an important tool to enable policymakers and industry actors to reformulate products available in the marketplace to reduce the risk of obesity and NCDs among populations.

Can methods based on spot urine samples be used to estimate average population 24 h sodium excretion? Results from the Isfahan Salt Study

OBJECTIVE

To assess agreement between established methods of estimating salt intake from spot urine collections and 24 h urinary Na (24hUNa) and then to develop a valid formula that can be used in the Iranian population to estimate salt intake from spot urine samples.

DESIGN

A validation study. Three spot urine samples were collected (fasting second-void morning; afternoon; evening) on the same day as a 24 h urine collection. We estimated 24hUNa from spot specimens using the Kawasaki, Tanaka and INTERSALT equations. Two new formulas were developed, the Iran formula 1 (Iran 1) and Iran formula 2 (Iran 2), based on our population characteristics.

SETTING

Iranian adults recruited in 2014-2015.

PARTICIPANTS

Healthy volunteer adults aged ≥18 years.

RESULTS

With all three spot urine specimens, predicted population 24hUNa was underestimated based on the INTERSALT equation (-469 to -708 mg/d; all P < 0·05) and conversely overestimation occurred with the Kawasaki equation (926 to 1080 mg/d; all P < 0·01). The Tanaka equation produced comparable estimates to measured 24hUNa (-151 to 86 mg/d; all P > 0·49). The newly derived formulas, Iran 1 and Iran 2, showed less mean bias than the established equations (Iran 1: 43 to 80 mg/d, all P > 0·55; Iran 2: 22 to 90 mg/d, all P > 0·50).

CONCLUSIONS

In this Iranian sample, the Tanaka equation and newly derived formulas produced group-level estimates comparable to measured 24hUNa. The newly developed formulas showed less mean bias than established equations; however, they need to be tested for generalization in a larger sample.

An Evaluation of the Sodium Content and Compliance with the National Sodium Reduction Targets among Packaged Foods Sold in Costa Rica in 2015 and 2018

High blood pressure is a leading cause of death in Costa Rica, with an estimated mortality rate of 30%. The average household sodium intake is two times higher than the World Health Organization recommendation. The consumption of processed foods is an important and growing contributor to sodium intake. The objective of this study was to describe the sodium content of packaged foods (mg/100 g) sold in Costa Rica in 2015 (n = 1158) and 2018 (n = 1016) and to assess their compliance with the national sodium reduction targets. All 6 categories with national targets were analyzed: condiments, cookies and biscuits, bread products, processed meats, bakery products, and sauces. A significant reduction in mean sodium content was found in only 3 of the 19 subcategories (cakes, tomato-based sauces, and tomato paste). No subcategories had statistically significant increases in mean sodium levels, but seasonings for sides/mains, ham, and sausage categories were at least 15% higher in sodium. Compliance with the national sodium targets among all foods increased from 80% in 2015 to 87% in 2018. The results demonstrate that it is feasible to reduce the sodium content in packaged foods in Costa Rica, but more work is needed to continually support a gradual reduction of sodium in packaged foods, including more stringent sodium targets.

Changing Sodium Knowledge, Attitudes and Intended Behaviours Using Web-Based Dietary Assessment Tools: A Proof-Of-Concept Study

Despite public health efforts to reduce dietary sodium, sodium intakes in most countries remains high. The purpose of this study was to determine if using novel web-based tools that provide tailored feedback, the Sodium Calculator and Sodium Calculator Plus, improves users' sodium-related knowledge, attitudes, and intended behaviours (KAB). In this single arm pre- and post-test study, 199 healthy adults aged 18-34 years completed a validated questionnaire to assess changes to sodium-related KAB before and after using the calculators. After using the calculators, the proportion of participants who accurately identified the sodium adequate intake and chronic disease risk reduction level increased (19% to 74% and 23% to 74%, respectively, both p = 0.021). The proportion accurately self-assessing their sodium intake as 'high' also increased (41% to 66%, p = 0.021). Several intended behavioural changes were reported, i.e., buying foods with sodium-reduced labels, using the Nutrition Facts table, using spices and herbs instead of salt, and limiting eating out. Evidence-based eHealth tools that assess and provide personalized feedback on sodium intake have the potential to aid in facilitating sodium reduction in individuals. This study is an important first step in evaluating and optimizing the implementation of eHealth tools to help reduce Canadians' sodium intakes.

Projecting burden of hypertension and its management in Turkey, 2015-2030

BACKGROUND

In Turkey, hypertension was responsible for 13% of total deaths in 2015. We apply existing research finding regarding the impact of a population-wide reduction in sodium consumption on the decrease of the hypertension prevalence rate among 15+ years population and the gender-age specific reduction in total death rates among 30+ years population, and compare hypertension burden, averted deaths, costs and benefits between two scenarios.

METHODS

The first scenario (i.e. status quo) assumes constant hypertension prevalence rate and the death rates between 2015 and 2030. Based on the Framingham Heart Study and INTERSALT Study findings on the impact of salt-reduction strategies on hypertension prevalence rate, the second scenario (Scenario II) assumes a 17% reduction in the prevalence of hypertension in Turkey in 2030, from its 2015 prevalence level. We project hypertension attributable disability adjusted life years (DALYs) in 2030, monetize DALYs using GDP (and income) per capita, and compare the projected economic benefits of DALYs averted and the additional costs associated with the increases in hypertension treatment through antihypertensive medications and physician consultations.

RESULTS

The estimated benefits of reducing the economic burden of hypertension deaths outweigh the cost of providing hypertension treatment. A decrease in hypertension prevalence by 17%, attributable to population-wide reduction in salt consumption, is projected to avert 24.3 thousand deaths in 2030. We projected that, compared to status quo, 392 thousand DALYs will be averted in Scenario II in 2030. The economic benefits of reduction in potential hypertension deaths are estimated to be 6.7 to 8.6 folds higher than the additional cost of hypertension treatment.

CONCLUSION

Population-wide hypertension prevention and management is a win-win situation for public health and the Turkish health care system as the economic benefits of reducing deaths and disabilities associated with hypertension outweigh the costs significantly.

Role of salt intake in prevention of cardiovascular disease: controversies and challenges

Strong evidence indicates that reduction of salt intake lowers blood pressure and reduces the risk of cardiovascular disease (CVD). The WHO has set a global target of reducing the population salt intake from the current level of approximately 10 g daily to <5 g daily. This recommendation has been challenged by several studies, including cohort studies, which have suggested a J-shaped relationship between salt intake and CVD risk. However, these studies had severe methodological problems, such as reverse causality and measurement error due to assessment of salt intake by spot urine. Consequently, findings from such studies should not be used to derail vital public health policy. Gradual, stepwise salt reduction as recommended by the WHO remains an achievable, affordable, effective, and important strategy to prevent CVD worldwide. The question now is how to reduce population salt intake. In most developed countries, salt reduction can be achieved by a gradual and sustained reduction in the amount of salt added to food by the food industry. The UK has pioneered a successful salt-reduction programme by setting incremental targets for >85 categories of food; many other developed countries are following the UK's lead. In developing countries where most of the salt is added by consumers, public health campaigns have a major role. Every country should adopt a coherent, workable strategy. Even a modest reduction in salt intake across the whole population can lead to a major improvement in public health and cost savings.

Risk factors for nutrition-related chronic disease among adults in Indonesia

OBJECTIVE

To conduct a secondary data analysis detailing the associations between sociodemographic and behavioral factors and nutrition-related chronic disease.

METHODS

These analyses utilized 2014 data from the Indonesian Family Life Survey, a home-based survey that collected socioeconomic, dietary intake, physical activity, and biological data among adults. We explored four outcomes in relation to sociodemographic and behavioral determinants: 1) hypertension, 2) elevated high-sensitivity c-reactive protein (hs-CRP), and 3) central obesity, as these are critical metabolic determinants in the progression to cardiovascular disease, and 4) type 2 diabetes. Hypertension was defined as systolic blood pressure ≥140 mm or diastolic blood pressure ≥ 90mm or current use of antihypertensive medication. Elevated hs-CRP was defined as hs-CRP >3 mg/dL. Central obesity was defined as waist circumference ≥ 90 cm if male and waist circumference ≥ 80 cm if female, which are specific to South Asia. Type 2 diabetes was defined as glycated hemoglobin ≥ 6.5%. We employed separate gender-stratified multivariate logistic regression models to test the associations between sociodemographic and behavioral determinants and each nutrition-related chronic disease outcome. All analyses employed sampling weights, which account for the survey design.

RESULTS

In 2014, about 30% of adults were hypertensive and one-fifth had elevated hs-CRP. Approximately 70% of women had central obesity and 11.6% of women and 8.9% of men had diabetes. Older-age was consistently associated with nutrition-related chronic disease and being overweight was associated with hypertension, elevated hs-CRP, and type 2 diabetes. Regularly consuming instant noodles (women) and soda (men) were associated with elevated hs-CRP and soda consumption was associated with central obesity among men.

CONCLUSIONS

Large segments of the adult population in Indonesia now have or are at risk for non-communicable disease. Our analyses provide preliminary empirical evidence that interventions that target healthful food intake (e.g. reduce the intake of ultra-processed foods) should be considered and that the reduction of overweight is critical for preventing chronic diseases in Indonesia.

The Evaluation of IDEAL-REACH Program to Improve Nutrition among Asian American Community Members in the Philadelphia Metropolitan Area

Objective Asian Americans' food purchasing, cooking, and eating patterns are not well understood. Greater insight into these behaviors is urgently needed to guide public health interventions of dietary behaviors in this population. The present study aims to examine the effects of a community-level intervention on food purchasing and preparation, nutrition knowledge, and health awareness in Asian Americans. Methods From 2015 to 2017, we conducted the Improving Diets with an Ecological Approach for Lifestyle (IDEAL-REACH) intervention to increase access to healthy food or beverage options for the Asian-American population in the Philadelphia metropolitan area. Participants (1110 at pre- and 1098 at post-assessment) were recruited from 31 community-based organizations (CBOs). We assessed Asian Americans' dietary behaviors, nutrition knowledge, and awareness of heart health. Results The results of pre-post intervention comparisons showed that the IDEAL-REACH intervention was successful in promoting whole grains consumption, reducing sodium consumption, and raising knowledge and awareness related to nutrition and heart health. Conclusions To our knowledge, this is one of the first initiatives in the U.S. to engage CBOs to promote healthier dietary behaviors. The findings show that CBOs serve as a powerful platform for community-level interventions to improve healthy nutrition behaviors in Asian-American communities.

Knowledge, Attitudes and Behaviours Related to Dietary Salt Intake in High-Income Countries: a Systematic Review

PURPOSE OF REVIEW

The purpose of this review was to examine the knowledge, attitudes and behaviours (KAB) related to dietary salt intake among adults in high-income countries.

RECENT FINDINGS

Overall (n = 24 studies across 12 countries), KAB related to dietary salt intake are low. While consumers are aware of the health implications of a high salt intake, fundamental knowledge regarding recommended dietary intake, primary food sources, and the relationship between salt and sodium is lacking. Salt added during cooking was more common than adding salt to food at the table. Many participants were confused by nutrition information panels, but food purchasing behaviours were positively influenced by front of package labelling. Greater emphasis of individual KAB is required from future sodium reduction programmes with specific initiatives focusing on consumer education and awareness raising. By doing so, consumers will be adequately informed and empowered to make healthier food choices and reduce individual sodium intake.

Comprehensive Approaches to Improving Nutrition: Future Prospects

When it comes to nutrition, nearly everyone has an opinion. In the past, nutrition was considered to be an individual's responsibility, however, more recently governments have been expected (by some) to share that responsibility by helping to ensure that marketing is responsible, and that food chains offer healthy meal choices in addition to their standard fare, for example. In some countries, governments have gone as far as to remove tax from unprocessed foods or to introduce taxes, such as that imposed on sugary soft drinks in the UK, Mexico, France and Norway. Following on from the sugar tax, chocolate might be next! Is this the answer to our burgeoning calorie intake and increasing poor nutritional status, or is there another approach? In this narrative we will focus on some of the approaches taken by communities and governments to address excess calorie intake and improve nutritional status, as well as some of the conflicts of interest and challenges faced with implementation. It is clear that in order to achieve meaningful change in the quality of nutritional intake and to reduce the long-term prevalence of obesity, a comprehensive approach is required wherein governments and communities work in genuine partnership. To take no or little action will doom much of today's youth to a poor quality of life in later years, and a shorter life expectancy than their grandparents.

Quantifying the impact of the Public Health Responsibility Deal on salt intake, cardiovascular disease and gastric cancer burdens: interrupted time series and microsimulation study

Background

In 2011, England introduced the Public Health Responsibility Deal (RD), a public-private partnership (PPP) which gave greater freedom to the food industry to set and monitor targets for salt intakes. We estimated the impact of the RD on trends in salt intake and associated changes in cardiovascular disease (CVD) and gastric cancer (GCa) incidence, mortality and economic costs in England from 2011–2025.

Methods

We used interrupted time series models with 24 hours' urine sample data and the IMPACT_NCD microsimulation model to estimate impacts of changes in salt consumption on CVD and GCa incidence, mortality and economic impacts, as well as equity impacts.

Results

Between 2003 and 2010 mean salt intake was falling annually by 0.20 grams/day among men and 0.12 g/d among women (P-value for trend both < 0.001). After RD implementation in 2011, annual declines in salt intake slowed statistically significantly to 0.11 g/d among men and 0.07 g/d among women (P-values for differences in trend both P < 0.001). We estimated that the RD has been responsible for approximately 9900 (interquartile quartile range (IQR): 6700 to 13,000) additional cases of CVD and 1500 (IQR: 510 to 2300) additional cases of GCa between 2011 and 2018. If the RD continues unchanged between 2019 and 2025, approximately 26 000 (IQR: 20 000 to 31,000) additional cases of CVD and 3800 (IQR: 2200 to 5300) cases of GCa may occur.

Interpretation

Public-private partnerships such as the RD which lack robust and independent target setting, monitoring and enforcement are unlikely to produce optimal health gains.

Sodium and Potassium Intake Assessed by Spot and 24-h Urine in the Population-Based Tromsø Study 2015-2016

Reduction of salt intake is a public health priority and necessitates the surveillance of salt intake in the population. The validity of salt intake assessed by dietary surveys is generally low. We, therefore, aimed to estimate salt intake by 24-h urine collection and to assess the usefulness of spot urine collection for surveillance purposes. In the population-based Tromsø Study 2015-2016, 493 men and women aged 40-69 years collected 24-h urine, of whom 475 also collected spot urine. Sodium and potassium excretions were calculated by multiplying respective urinary concentrations by the total volume of urine. Based on the sodium concentration in spot urine, we also estimated 24-h sodium excretion by three different equations. Mean sodium excretion was 4.09 ± 1.60 and 2.98 ± 1.09 g/24-h in men and women, respectively, corresponding to a calculated salt intake of 10.4 and 7.6 g. The sodium to potassium molar (Na/K) ratio was approximately 1.8 in both genders. Of the three equation utilizing spot urine, estimated mean 24-h sodium excretion was closest for the INTERSALT formulae (4.29 and 2.96 g/24-h in men and women, respectively). In this population-based study, the estimated salt intake was higher than the recommended intake. However, urine potassium excretion was rather high resulting in a favorable Na/K ratio. Mean sodium excretion calculated from spot urine by the INTERSALT equation predicted the mean sodium excretion in 24-h urine reasonably well.

The Science of Salt: A global review on changes in sodium levels in foods

This review aims to summarize and synthesize studies reporting on changes in sodium levels in packaged food products, restaurant foods, and hospital or school meals, as a result of salt reduction interventions. Studies were extracted from those published in the Science of Salt Weekly between June 2013 and February 2018. Twenty-four studies were identified: 17 assessed the changes in packaged foods, four in restaurant foods, two in hospital or school meals, and one in both packaged and restaurant foods. Three types of interventions were evaluated as part of the studies: voluntary reductions (including targets), labeling, and interventions in institutional settings. Decreases in sodium were observed in all studies (n = 8) that included the same packaged foods matched at two time points, and in the studies carried out in hospitals and schools. However, there was little to no change in mean sodium levels in restaurant foods. The pooled analysis of change in sodium levels in packaged foods showed a decrease in sodium in unmatched food products (-36 mg/100 g, 95% CI -51 to -20 mg/100 g) and in five food categories-breakfast cereals, breads, processed meats, crisps and snacks, and soups. Twenty-two of the 24 studies were from high-income countries, limiting the applicability of the findings to lower resource settings.

Twenty-Four-Hour Urinary Sodium and Potassium Excretion in China: A Systematic Review and Meta-Analysis

Background

In China, high sodium and low potassium intakes result in elevated blood pressure, a major cause of cardiovascular disease, yet the intake estimates lack accuracy and nutritional strategies remain limited.

Methods and Results

We aimed to determine sodium and potassium intake by systematically searching for and quantitatively summarizing all published 24‐hour urinary sodium and potassium data (ie, the most accurate method). MEDLINE, EMBASE, Scopus, China National Knowledge Infrastructure, and Wanfang were searched up to February 2019. All studies reporting 24‐hour urinary sodium or potassium in China were included; hospitalized patients were excluded. Data were pooled using random‐effects meta‐analysis and heterogeneity was explored with meta‐regression. Sodium data were reported in 70 studies (n=26 767), 59 of which also reported potassium (n=24 738). Mean sodium and potassium excretions were 86.99 mmol/24 h (95% CI, 69.88–104.10) and 14.65 mmol/24 h (95% CI, 11.10–18.20) in children aged 3 to 6 years, 151.09 mmol/24 h (95% CI, 131.55–170.63) and 25.23 mmol/24 h (95% CI, 22.37–28.10) in children aged 6 to 16 years, and 189.07 mmol/24 h (95% CI, 182.14–195.99) and 36.35 mmol/24 h (95% CI, 35.11–37.59) in adults aged >16 years. Compared with southern China, sodium intake was higher in northern China (P<0.0001) but is declining (P=0.0066).

Conclusions

Average sodium intake in all age groups across China is approximately double the recommended maximum limits, and potassium intake is less than half that recommended. Despite a decline, sodium intake in northern China is still among the highest in the world, and the North–South divide persists. Urgent action is needed to simultaneously reduce sodium and increase potassium intake across China.

An Application-based programme to reinforce and maintain lower salt intake (AppSalt) in schoolchildren and their families in China

INTRODUCTION

Salt intake is very high in China, with ≈80% being added by the consumers. It is difficult to reduce salt in such settings. Our previous study (School-based Education programme to reduce Salt(School-EduSalt)) demonstrated that educating schoolchildren, who then instructed their families to reduce the amount of salt used at home, is effective in lowering salt intake in both children and adults. Our team also developed an app called 'KnowSalt', which could help individuals to estimate their salt intake and the major sources of salt in the diet. Building on School-EduSalt and KnowSalt, we propose to develop a new app (AppSalt) focusing on salt reduction through education, target setting, monitoring, evaluation, decision support and management to achieve a progressive lower salt intake for long term. To evaluate the effectiveness of the AppSalt programme, we will carry out a cluster randomised controlled trial.

METHODS AND ANALYSIS

We will recruit 54 primary schools from urban and rural areas of three provinces in China. A total of 594 children aged 8-9 years and 1188 adult family members will be randomly selected for evaluation. After baseline assessment, schools will be randomly allocated to either the intervention or control group. Children in the intervention group will be taught, with support of AppSalt, about salt reduction and assigned homework to get the whole family involved in the activities to reduce salt consumption. The duration of the intervention is two school terms (ie, 1 year). The primary outcome is the difference between the intervention and control group in the change of salt intake as measured by 24-hour urinary sodium.

ETHICS AND DISSEMINATION

The study has been approved by Queen Mary Research Ethics Committee and Peking University Health Science Centre IRB. Results will be disseminated through presentations, publications and social media.

TRIAL REGISTRATION NUMBER

ChiCTR1800017553.

Monitoring Sodium Content in Processed Foods in Argentina 2017-2018: Compliance with National Legislation and Regional Targets

Sodium intake in Argentina has been estimated to be at least double the dose of 2000 mg/day recommended by WHO, mostly coming from processed foods. Argentina is one of the few countries in the world that have regulated sodium content in certain food products. This study presents an assessment of sodium content in a selection of food groups and categories as reported in the nutrient information panels. We surveyed 3674 food products, and the sodium content of 864 and 1375 of them was compared to the maximum levels according to the Argentinean law and the regional targets, respectively. All food categories presented high variability of sodium content. Over 90% of the products included in the national sodium reduction law were found to be compliant. Food groups with high median sodium, such as condiments, sauces and spreads, and fish and fish products, are not included in the national law. In turn, comparisons with the lower regional targets indicated that almost 50% of the products analyzed had sodium contents above the recommended values. This evidence suggests that enhancing sodium reduction in processed foods may be a necessity for public health objectives and it is also technically feasible in Argentina.

Dietary Sources of Salt in Low- and Middle-Income Countries: A Systematic Literature Review

Rapid urbanization in low- and middle-income countries (LMICs) is transforming dietary patterns from reliance on traditional staples to increased consumption of energy-dense foods high in saturated fats, trans fats, sugars, and salt. A systematic literature review was conducted to determine major food sources of salt in LMICs that could be targeted in strategies to lower population salt intake. Articles were sourced using Medline, Web of Science, Scopus, and grey literature. Inclusion criteria were: reported dietary intake of Na/salt using dietary assessment methods and food composition tables and/or laboratory analysis of salt content of specific foods in populations in countries defined as low or middle income (LMIC) according to World Bank criteria. Of the 3207 records retrieved, 15 studies conducted in 12 LMICs from diverse geographical regions met the eligibility criteria. The major sources of dietary salt were breads, meat and meat products, bakery products, instant noodles, salted preserved foods, milk and dairy products, and condiments. Identification of foods that contribute to salt intake in LMICs allows for development of multi-faceted approaches to salt reduction that include consumer education, accompanied by product reformulation.

Evaluation of an education program based on the theory of planned behavior for salt intake in individuals at risk of hypertension

This study was conducted to evaluate an education program based on the theory of planned behavior (TPB) for salt intake in individuals at risk of hypertension. This randomized controlled trial was conducted from February 2017 to December 2017 in Shahediyeh, Yazd Province, Iran. For this purpose, 140 people were selected and assigned to two groups of 70 each, namely, intervention and control. Data were gathered by a self-administered TPB based questionnaire, and also 24-h urinary sodium and potassium levels and systolic and diastolic blood pressure were measured. The intervention group received TPB based on a training package, while the control group received no intervention. Post-test was administered 2 months after completion of the intervention. Independent and paired t-tests, χ2 and analysis of covariance (ANCOVA) were used for data analysis. All mean scores on TPB constructs increased significantly except motivation to comply and power of control for intervention group. Average salt intake decreased in intervention group compared with the control group (-4.73 g/day �0.73 versus -0.24 g/day �0.94, P < 0.001), but systolic and diastolic blood pressure did not change significantly in intervention group compared with control group. TPB can be implemented along with other approaches in educational programs to reduce salt intake. Code: IRCT201701108803N3.

The Science of Salt: Updating the evidence on global estimates of salt intake

The Global Burden of Disease (GBD) 2010 study estimated national salt intake for 187 countries based on data available up to 2010. The purpose of this review was to identify studies that have measured salt intake in a nationally representative population using the 24-hour urine collection method since 2010, with a view to updating evidence on population salt intake globally. Studies published from January 2011 to September 2018 were searched for from MEDLINE, Scopus, and Embase databases using relevant terms. Studies that provided nationally representative estimates of salt intake among the healthy adult population based on the 24-hour urine collection were included. Measured salt intake was extracted and compared with the GBD estimates. Of the 115 identified studies assessed for eligibility, 13 studies were included: Four studies were from Europe, and one each from the United States, Canada, Benin, India, Samoa, Fiji, Barbados, Australia, and New Zealand. Mean daily salt intake ranged from 6.75 g/d in Barbados to 10.66 g/d in Portugal. Measured mean population salt intake in Italy, England, Canada, and Barbados was lower, and in Fiji, Samoa, and Benin was higher, in recent surveys compared to the GBD 2010 estimates. Despite global targets to reduce population salt intake, only 13 countries have published nationally representative salt intake data since the GBD 2010 study. In all countries, salt intake levels remain higher than the World Health Organization's recommendation, highlighting the need for additional global efforts to lower salt intake and monitor salt reduction strategies.

Prediction of 24-hour sodium excretion from spot urine samples in South African adults: a comparison of four equations

Repeated 24-hour urine collection is considered to be the gold standard for assessing salt intake. This is often impractical in large-population studies, especially in low-middle-income countries. Equations to estimate 24-hour urinary salt excretion from a spot urine sample have been developed, but have not been widely validated in African populations. This study aimed to systematically assess the validity of four existing equations to predict 24-hour urinary sodium excretion (24UNa) from spot urine samples in a nationally representative sample of South Africans. Spot and 24-hour urine samples were collected in a subsample (n = 438) of participants from the World Health Organisation Study on global AGEing and adult health (SAGE) Wave 2 in South Africa in 2015. Measured 24UNa values were compared with predicted 24UNa values from the Kawasaki, Tanaka, INTERSALT and Mage equations using Bland-Altman plots. In this subsample (mean age 52.8 ± 16.4 years; body mass index 30.2 ± 8.2 kg/m²; 76% female; 73% black African; 42% hypertensive), all four equations produced a significantly different population estimate compared with the measured median value of 6.7 g salt/day (IQR 4.4-10.5). Although INTERSALT underestimated salt intake (-3.77 g/d; -1.64 to -7.09), the other equations overestimated by 1.28 g/d (-3.52; 1.97), 6.24 g/d (2.22; 9.45), and 17.18 g/d (8.42; 31.96) for Tanaka, Kawasaki, and Mage, respectively. Bland-Altman curves indicated unacceptably wide levels of agreement. Use of these equations to estimate population level salt intake from spot urine samples in South Africans is not recommended.

Intake of 12 food groups and disability-adjusted life years from coronary heart disease, stroke, type 2 diabetes, and colorectal cancer in 16 European countries

Our aim was to estimate and rank 12 food groups according to disability-adjusted life years (DALYs) from coronary heart disease (CHD), stroke, type 2 diabetes (T2D), and colorectal cancer (CRC) in 16 European countries. De novo published non-linear dose-response meta-analyses of prospective studies (based on 297 primary reports), and food consumption data from the European Food Safety Authority Comprehensive European Food Consumption Database in Exposure Assessment, and DALY estimates from the Institute for Health Metrics and Evaluation were used. By implementing disease-specific counterfactual scenarios of theoretical minimum risk exposure level (TMRELs), the proportion of DALYs attributed to 12 food groups was estimated. In addition, a novel modelling approach was developed to obtain a single (optimized) TMREL across diseases. Four scenarios were analysed (A: disease-specific TMRELs/all food-disease associations; B: disease-specific TMRELs/only significant food-disease associations; C: single TMREL/all food-disease associations; D: single TMREL/only significant food-disease associations). Suboptimal food intake was associated with the following proportions of DALYs; Scenario A (highest-estimate) and D (lowest-estimate): CHD (A: 67%, D: 52%), stroke (A: 49%, D: 30%), T2D (A: 57%, D: 51%), and CRC (A: 54%, D: 40%). Whole grains (10%) had the highest impact on DALYs, followed by nuts (7.1%), processed meat (6.4%), fruit (4.4%) and fish and legumes (4.2%) when combining all scenarios. The contribution to total DALYs of all food groups combined in the different scenarios ranged from 41-52% in Austria to 51-69% in the Czech-Republic. These findings could have important implications for planning future food-based dietary guidelines as a public health nutrition strategy.

Mean Dietary Salt Intake in Vanuatu: A Population Survey of 755 Participants on Efate Island

Non-communicable diseases are responsible for 63% of global deaths, with a higher burden in low- and middle-income countries. Hypertension is the leading cause of cardiovascular-disease-related deaths worldwide, and approximately 1.7 million deaths are directly attributable to excess salt intake annually. There has been little research conducted on the level of salt consumption amongst the population of Vanuatu. Based on data from other Pacific Island countries and knowledge of changing regional diets, it was predicted that salt intake would exceed the World Health Organization’s (WHO) recommended maximum of 5 g per day. The current study aimed to provide Vanuatu with a preliminary baseline assessment of population salt intake on Efate Island. A cross-sectional survey collected demographic, clinical, and urine data from participants aged 18 to 69 years in rural and urban communities on Efate Island in October 2016 and February 2017. Mean salt intake was determined to be 7.2 (SD 2.3) g/day from spot urine samples, and 5.9 (SD 3.6) g/day from 24-h urine samples, both of which exceed the WHO recommended maximum. Based on the spot urine samples, males had significantly higher salt intake than females (7.8 g compared to 6.5 g; p < 0.001) and almost 85% of the population consumed more than the WHO recommended maximum daily amount. A coordinated government strategy is recommended to reduce salt consumption, including fiscal policies, engagement with the food industry, and education and awareness-raising to promote behavior change.

Priorities to reduce the burden of stroke in Latin American countries

The large and increasing burden of stroke in Latin American countries, and the need to meet the UN and WHO requirements for reducing the burden from non-communicable disorders (including stroke), brought together stroke experts and representatives of the Ministries of Health of 13 Latin American countries for the 1st Latin American Stroke Ministerial meeting in Gramado, Brazil, to discuss the problem and identify ways of cooperating to reduce the burden of stroke in the region. Discussions were focused on the regional and country-specific activities associated with stroke prevention and treatment, including public stroke awareness, prevention strategies, delivery and organisation of care, clinical practice gaps, and unmet needs. The meeting culminated with the adoption of the special Gramado Declaration, signed by all Ministerial officials who attended the meeting. With agreed priorities for stroke prevention, treatment, and research, an opportunity now exists to translate this Declaration into an action plan to reduce the burden of stroke.

Application of Mobile Health Technologies Aimed at Salt Reduction: Systematic Review

Background

High salt consumption has contributed to the rise of noncommunicable diseases around the world. The application of mobile health (mHealth) technologies has witnessed rapid growth in recent years. However, evidence to support mHealth interventions to confront the challenge of salt reduction has not yet been critically reviewed.

Objective

The aim of this study was to identify, characterize, and evaluate mHealth interventions aimed at salt reduction across the world.

Methods

A systematic search of studies in English or Chinese language published from January 1, 1992 to July 31, 2017 was conducted using 4 English databases (PubMed, MEDLINE, Global Health, and Cochrane) and 3 Chinese databases (Wanfang, China Science and Technology Journal, and China National Knowledge of Infrastructure). All studies directly using mobile technologies in health care with a primary or secondary objective of reducing dietary salt consumption were included.

Results

A total of 1609 articles were found using the search strategy, with 11 full articles (8 English and 3 Chinese) being included for data extraction, including 11 interventional studies. Overall, few high-quality interventions were identified. Most interventions were limited by small study population sample sizes, lack of control groups, and short follow-up times, all of which were obstacles in generating long-term scalable approaches. Most interventions employed short message service as a platform for mHealth interventions, whereas some innovative mHealth technologies were also explored. Most interventions had a primary focus of improving awareness of dietary salt consumption. The outcome variables used to measure intervention effectiveness included 24-hour urinary sodium excretion, spot urine sampling, dietary records, and indirect behavior or knowledge indicators targeting salt consumption. Although most interventions displayed positive outcome results, none of them provided reliable evidence to evaluate the effectiveness of salt reduction.

Conclusions

Salt reduction in mHealth initiatives remains relatively unexplored; however, studies that did intervene on salt-reduction show the potential of mHealth as an effective intervention method. We provide 3 recommendations for future mHealth interventions in salt reduction—(1) increased use of new, innovative, and interactive mHealth technologies; (2) development of mHealth interventions with primary prevention measures and goals of salt reduction; and (3) large-scale, rigorously designed, and object-targeted clinical trials of mHealth interventions with appropriate quantitative outcome variables, in particular 24-hour urine sodium.

Joint association of urinary sodium and potassium excretion with cardiovascular events and mortality: prospective cohort study

OBJECTIVE

To evaluate the joint association of sodium and potassium urinary excretion (as surrogate measures of intake) with cardiovascular events and mortality, in the context of current World Health Organization recommendations for daily intake (<2.0 g sodium, >3.5 g potassium) in adults.

DESIGN

International prospective cohort study.

SETTING

18 high, middle, and low income countries, sampled from urban and rural communities.

PARTICIPANTS

103 570 people who provided morning fasting urine samples.

MAIN OUTCOME MEASURES

Association of estimated 24 hour urinary sodium and potassium excretion (surrogates for intake) with all cause mortality and major cardiovascular events, using multivariable Cox regression. A six category variable for joint sodium and potassium was generated: sodium excretion (low (<3 g/day), moderate (3-5 g/day), and high (>5 g/day) sodium intakes) by potassium excretion (greater/equal or less than median 2.1 g/day).

RESULTS

Mean estimated sodium and potassium urinary excretion were 4.93 g/day and 2.12 g/day, respectively. After a median follow-up of 8.2 years, 7884 (6.1%) participants had died or experienced a major cardiovascular event. Increasing urinary sodium excretion was positively associated with increasing potassium excretion (unadjusted r=0.34), and only 0.002% had a concomitant urinary excretion of <2.0 g/day of sodium and >3.5 g/day of potassium. A J-shaped association was observed of sodium excretion and inverse association of potassium excretion with death and cardiovascular events. For joint sodium and potassium excretion categories, the lowest risk of death and cardiovascular events occurred in the group with moderate sodium excretion (3-5 g/day) and higher potassium excretion (21.9% of cohort). Compared with this reference group, the combinations of low potassium with low sodium excretion (hazard ratio 1.23, 1.11 to 1.37; 7.4% of cohort) and low potassium with high sodium excretion (1.21, 1.11 to 1.32; 13.8% of cohort) were associated with the highest risk, followed by low sodium excretion (1.19, 1.02 to 1.38; 3.3% of cohort) and high sodium excretion (1.10, 1.02 to 1.18; 29.6% of cohort) among those with potassium excretion greater than the median. Higher potassium excretion attenuated the increased cardiovascular risk associated with high sodium excretion (P for interaction=0.007).

CONCLUSIONS

These findings suggest that the simultaneous target of low sodium intake (<2 g/day) with high potassium intake (>3.5 g/day) is extremely uncommon. Combined moderate sodium intake (3-5 g/day) with high potassium intake is associated with the lowest risk of mortality and cardiovascular events.

Understanding Barriers and Enablers to State Action on Salt: Analysis of Stakeholder Perceptions of the VicHealth Salt Reduction Partnership

The Victorian Salt Reduction Partnership (VicSalt Partnership) was launched in 2015, bringing together health and research organisations to develop an action plan for salt reduction interventions at a state level. A comprehensive evaluation was designed to assess the impact of the resulting four-year intervention strategy. As part of the process evaluation, semi-structured interviews were undertaken with stakeholders in March⁻May 2017, to understand perceived barriers and enablers to effective strategy implementation. Data were coded in relation to the key topic areas of the interviews with an inductive method used to analyse themes within topics. Seventeen stakeholders were contacted, 14 completed an interview; five from state government or statutory agencies, four from non-government funded organisations, four from research organisations and one from the food industry. Twelve were members of the VicSalt Partnership and two were informal collaborators. Most stakeholders viewed the VicSalt Partnership as a positive example of working collaboratively, and said this was essential for raising awareness of the importance of salt reduction with consumers, the food industry, and the government. Challenges relating to engaging the food industry and federal government through a state-led initiative were identified. New approaches to overcome this, such as forming clear "asks" to government and committing industry to "pledges" on reformulation were suggested. Stakeholder interviews and qualitative analysis have provided a range of important insights into barriers and enablers, many of which have already been used to strengthen intervention implementation. The evaluation of the VicSalt Partnership is ongoing and the program is expected to provide a wealth of lessons for state-led interventions to reduce salt intake in Australia and globally.

Contribution of fat, sugar and salt to diets in the Pacific Islands: a systematic review

OBJECTIVE

Pacific Island countries are experiencing a high burden of diet-related non-communicable diseases; and consumption of fat, sugar and salt are important modifiable risk factors contributing to this. The present study systematically reviewed and summarized available literature on dietary intakes of fat, sugar and salt in the Pacific Islands.

DESIGN

Electronic databases (PubMed, Scopus, ScienceDirect and GlobalHealth) were searched from 2005 to January 2018. Grey literature was also searched and key stakeholders were consulted for additional information. Study eligibility was assessed by two authors and quality was evaluated using a modified tool for assessing dietary intake studies.

RESULTS

Thirty-one studies were included, twenty-two contained information on fat, seventeen on sugar and fourteen on salt. Dietary assessment methods varied widely and six different outcome measures for fat, sugar and salt intake - absolute intake, household expenditure, percentage contribution to energy intake, sources, availability and dietary behaviours - were used. Absolute intake of fat ranged from 25·4 g/d in Solomon Islands to 98·9 g/d in Guam, while salt intake ranged from 5·6 g/d in Kiribati to 10·3 g/d in Fiji. Only Guam reported on absolute sugar intake (47·3 g/d). Peer-reviewed research studies used higher-quality dietary assessment methods, while reports from national surveys had better participation rates but mostly utilized indirect methods to quantify intake.

CONCLUSIONS

Despite the established and growing crisis of diet-related diseases in the Pacific, there is inadequate evidence about what Pacific Islanders are eating. Pacific Island countries need nutrition monitoring systems to fully understand the changing diets of Pacific Islanders and inform effective policy interventions.

Knowledge, attitudes and practices related to dietary salt intake among adults in North India

OBJECTIVE

To assess the knowledge, attitudes and practices related to salt consumption among adults in rural and urban North India.

DESIGN

Data for the study were obtained from a community-based cross-sectional survey using an interviewer-administered questionnaire and 24 h urine samples.

SETTING

Data collection was conducted during March-October 2012 in rural Haryana and urban Delhi in North India.

PARTICIPANTS

Adults (n 1635) aged ≥20 years (701 in rural Haryana; 934 in urban Delhi).

RESULTS

Twenty-four per cent of rural and 40·5 % of urban participants knew that a high-salt diet causes high blood pressure. Nearly one-fifth of both rural and urban participants knew that there should be a maximum daily limit for consumption of salt. In rural and urban areas, 46·6 and 45·1 %, respectively, perceived it important to reduce the salt content of their diet; however, only 3·7 and 10·2 %, respectively, reported taking some actions. Participants reported they were consuming 'too little salt', 'just the right amount of salt' or 'too much salt', but their corresponding mean (95 % CI) actual salt consumption (g/d; as measured by 24 h urinary Na excretion) was higher, especially among rural participants (rural: 9·2 (8·13, 10·22), 8·5 (8·19, 8·77) or 8·4 (7·72, 8·99); urban: 5·6 (4·67, 6·57), 5·7 (5·32, 6·01) or 4·6 (4·10, 5·14), respectively).

CONCLUSIONS

Knowledge about the deleterious health impact of excess salt consumption is low in this population. Tailored public education for salt reduction is warranted with a particular focus on rural residents.

Using regulation to limit salt intake and prevent non-communicable diseases: lessons from South Africa's experience

OBJECTIVE

To analyse the policy process for the South African regulation setting upper limits for salt in thirteen commonly consumed food categories, to inform future policy action for prevention of non-communicable diseases.

DESIGN

Semi-structured interviews (n 10) were conducted with key stakeholders from government, academia, non-governmental organisations and the food industry. Interviewees were asked about the content, context, process and actors involved in developing the regulation. Data were analysed according to Walt and Gilson's health policy analysis triangle.

SETTING

South Africa.ParticipantsKey actors and stakeholders in the policy process to develop the salt regulation.

RESULTS

The regulation was a response to research establishing the effectiveness of food supply interventions and to a shared perception that government regulation was the quickest way to address the problem of salt overconsumption. While the regulations were developed through a consultative process, food industry stakeholders perceived the consultation as inadequate. Implementation is currently underway, supported by a health promotion programme. Monitoring and enforcement were identified as the most likely challenges due to capacity constraints.

CONCLUSIONS

Comprehensive mandatory salt limits are an innovative approach to food reformulation. Factors that enabled regulation included robust scientific evidence, strong political and bureaucratic leadership, and the pragmatic use of existing regulatory instruments. The main challenges identified were disagreement over the appropriate nature and extent of food industry participation, and monitoring and enforcement challenges due to capacity constraints.

Sodium Content of Processed Foods Available in the Mexican Market

BACKGROUND

Sodium intake is related to several adverse health outcomes, such as hypertension and cardiovascular diseases. Processed foods are major contributors to the population's sodium intake. The aim of the present study was to determine sodium levels in Mexican packaged foods, as well as to evaluate the proportion of foods that comply with sodium benchmark targets set by the United Kingdom Food Standards Agency (UK FSA) and those set by the Mexican Commission for the Protection of Health Risks (COFEPRIS). We also evaluated the proportion of foods that exceeded the Pan American Health Organization (PAHO) targets.

METHODS

This was a cross-sectional study that comprised data collected from the package of 2248 processed foods from selected supermarkets in Mexico.

RESULTS

Many processed food categories contained an excessive amount of sodium. Processed meats, ham, bacon and sausages, had the highest concentrations. The proportion of foods classified as compliant in our sample was lower for international targets (FSA UK and PAHO) compared to the Mexican COFEPRIS criteria.

CONCLUSIONS

These data provided a critical baseline assessment for monitoring sodium levels in Mexican processed foods.

Sodium Levels of Processed Meat in Australia: Supermarket Survey Data from 2010 to 2017

High sodium intake increases blood pressure and consequently increases the risk of cardiovascular diseases. In Australia, the best estimate of sodium intake is 3840 mg sodium/day, almost double the World Health Organization (WHO) guideline (2000 mg/day), and processed meats contribute approximately 10% of daily sodium intake to the diet. This study assessed the median sodium levels of 2510 processed meat products, including bacon and sausages, available in major Australian supermarkets in 2010, 2013, 2015 and 2017, and assessed changes over time. The median sodium content of processed meats in 2017 was 775 mg/100 g (interquartile range (IQR) 483⁻1080). There was an 11% reduction in the median sodium level of processed meats for which targets were set under the government's Food and Health Dialogue (p < 0.001). This includes bacon, ham/cured meat products, sliced luncheon meat and meat with pastry categories. There was no change in processed meats without a target (median difference 6%, p = 0.450). The new targets proposed by the current government's Healthy Food Partnership capture a larger proportion of products than the Food and Health Dialogue (66% compared to 35%) and a lower proportion of products are at or below the target (35% compared to 54%). These results demonstrate that voluntary government targets can drive nutrient reformulation. Future efforts will require strong government leadership and robust monitoring and evaluation systems.